Cost-effectiveness of clopidogrel in myocardial infarction with ST-segment elevation:: A European model based on the CLARITY and COMMIT trials

Background: Several health economic studies have shown that the use of clopidogrel is cost-effective to prevent ischemic events in non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina. Objective: This study was designed to assess the cost-effectiveness of clopidogrel in short- and long-term treatment of ST-segment elevation myocardial infarction (STEMI) with the use of data from 2 trials in Sweden, Germany, and France: CLARITY (Clopidogrel as Adjunctive Reperfusion Therapy) and COMMIT (Clopidogrel and Metoprolol in Myocardial Infarction Trial). Methods: A combined decision tree and Markov model was constructed. Because existing evidence indicates similar long-term outcomes after STEMI and NSTEMI, data from the long-term NSTEMI CURE trial (Clopidogrel in Unstable Angina to Prevent Recurrent Events) were combined with 1-month data from CLARITY and COMMIT to model the effect of treatment up to 1 year. The risks of death, myocardial infarction, and stroke in an untreated population and long-term survival after all events were derived from the Swedish Hospital Discharge and Cause of Death register. The model was run separately for the 2 STEMI trials. A payer perspective was chosen for the comparative analysis, focusing on direct medical costs. Costs were derived from published sources and were converted to 2005 euros. Effectiveness was measured as the number of life-years gained (LYG) from clopidogrel treatment. Results: In a patient cohort with the same characteristics and event rates as in the CLARITY population, treatment with clopidogrel for up to 1 year resulted in 0.144 LYG. In Sweden and France, this strategy was dominant with estimated cost savings of (sic)111 and (sic)367, respectively. In Germany, clopidogrel treatment had an incremental cost-effectiveness ratio (ICER) of (sic)92/LYG. Data from the COMMIT study showed that clopidogrel treatment resulted in 0.194 LYG at an incremental cost of (sic)538 in Sweden, (sic)798 in Germany, and (sic)545 in France. The corresponding ICERs were (sic)2772/LYG, (sic)4144/LYG, and (sic)2786/LYG, respectively. Conclusions: Treatment of these STEMI patients with clopidogrel appeared to be cost-effective in all 3 European countries studied. Predicted ICERs were below generally accepted threshold values.